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Fiske  Fund  Prize  Essay.    No.  LVII. 


THE  ROLE  OF  THE  TEETH  AND 
TONSILS 

IN  THE 

CAUSATION  OF  ARTHRITIS 


MOTTO • 

DUM  SPIRO,  SPERO;      CUM    NOTIS   VARIORUM. 


Author: 


DR.  JOSEPH  F.  HAWKINS, 
Providence,  R.  I. 


Snow  &  Farnham  Co.,  Printers 

Providence,  R.  I. 

1917 


3 

1> 


THE  Trustees  of  the  Fiske  Fund,  at  the  annual  meeting  of  the 
Rhode  Island  Medical  Society,  held  at  Providence,  May  31, 1917, 
announced  that  they  had  awarded  a  premium  of  two  hundred  dollars 
to  an  essay  on  "The  Role  of  the  Teeth  and  Tonsils  in  the  Causation 
of  Arthritis,"  bearing  the  motto: 

"Dum  spiro,  spero;  cum  Notis  variorum." 

The  author  was  found  to  be  Dr.  Joseph  F.  Hawkins,  of  Providence, 
R.I. 

DR.  EDMUND  D.  CHESEBRO,  Providence,  R.  I., 

DR.  JOHN  CHAMPLIN,  Westerly,  R.  I., 

DR.  GARDNER  T.  SWARTS,  Providence,  R.  I., 

Trustees. 

HALSEY  DeWOLF,  M.  D., 

Secretary  of  the  Trustees, 

305  Brook  Street,  Providence,  R.  I. 


The  Role  of  the  Teeth  and  Tonsils  in  the 
Causation  of  Arthritis. 


That  the  absorption  of  chemical  toxins  from 
micro-organisms  can  and  does  produce  serious 
pathological  lesions  in  the  organs,  glands  and 
joints  of  the  body  is  an  established  and  accepted 
fact  by  the  medical  man  who  is  abreast  of  the  latest 
research  in  experimental  medicine. 

To  have  an  acute  tonsillitis  the  initial  event  of 
an  acute  rheumatic  attack  is  so  common  that  it 
is  now  generally  accepted  as  a  clinical  fact,  and, 
upon  minute  history  taking,  one  will  find  it  in  the 
majority  of  cases.  As  far  back  as  1798  Eyerlen1 
noted  that  not  only  in  primary  attacks  of  rheu- 
matic fever,  but  in  subsequent  attacks,  there  was 
a  history  of  tonsillitis  preceding.  Other  observers 
have  noted  this  fact  and  recorded  their  opinions:3 
that  they  found  sore  throats  as  a  precedent 
in  from  1.5%  to  80%  of  the  cases.  It  is  evident 
to  every  clinical  observer  that,  many  times,  a  con- 
stant forerunner  of  almost  any  systemic  disturb- 
ance is  of  so  slight  importance  that  it  may  be  over- 
looked or  not  mentioned  by  the  patient  unless 
brought  out  by  the  questioning  of  the  physician; 
while,  on  the  other  hand,  there  might  be  quite 
serious  disease  in  or  about  the  teeth  and  tonsils, 
with  little  or  no  local  manifestation.     Tonsils  are 


6  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

removed  in  children  usually  on  account  of  their 
size.  They  are  obstructive  mechanically.  In 
adults  the  tonsils  may  be  small,  even  to  being  com- 
pletely submerged  out  of  the  line  of  vision  of  the 
observer,  yet  be  an  infected,  toxin-producing, 
chronic  poisoning  source  of  various  vague  pains, 
and  would  never  be  removed  for  the  same  reason 
as  in  childhood,  but  when  removed,  have  proved 
to  have  been  the  grave  menace  just  mentioned. 
Recent  writers,  employing  better  methods  of  ex- 
amining the  teeth  and  tonsils,  are  finding  many 
more  cases  of  arthritis  when  these  organs  are 
diseased  than  formerly.  Goadby,4  and  others,  re- 
port cases  of  polyarthritis  originating  in  pus 
pockets  about  the  teeth,  and  all  are  apparently 
agreed,  at  this  time,  that  the  most  frequent  port 
of  entry  is  there  or  through  the  tonsils.  As  far 
back  as  1904  Gurich,5  who,  by  the  way,  believed 
that  joint  symptoms,  endocarditis,  pericarditis, 
pneumonia,  myocarditis,  pleurisy,  and  all  the 
other  complications  of  an  acute  rheumatic  fever, 
were  all  the  result  of  metastases  from  a  primary 
focus  elsewhere  in  the  body,  was  the  first  to  at- 
tempt systemic  treatment  of  acute  rheumatic  fever 
through  the  tonsils.  He  reports  12  cases  of  ton- 
sillitis and  four  of  peritonsillar  abscess  preceding 
the  appearance  of  the  acute  arthritis,  and  14  cases 
where  plugs  were  seen  in  the  crypts.  A  year  later 
he  reported6 140  cases  of  acute  and  chronic  arthritis 
treated  by  tonsillar  therapy,  with  98  cures  and  23 
cases  unaffected  by  the  treatment,  which  consisted 


IN   THE   CAUSATION   OF   ARTHRITIS.  7 

of  making  parallel  incisions  through  the  tonsils 
and  curetting  the  tonsillar  tissue.  Enucleation 
was  not  done  at  that  time.  Four  years  later 
Rosenheim7  reported  10  cases  of  acute  articular 
rheumatism  treated  by  tonsillectomy  and  he  was 
probably  the  first  to  enucleate  the  tonsils  in  acute 
rheumatic  fever.  One  year  later  Hess8  stated  he 
thought  acute  follicular,  phlegmonous,  catarrhal 
tonsillitis  or  quinsy  ushered  in  attacks  of  arthritis, 
and  emphasized  the  importance  of  the  tonsils  in  the 
etiology  of  the  disease,  but  did  not  resort  to  sur- 
gical treatment  of  the  tonsils.  One  year  later  still, 
1910,  Schichold9  reported  70  cases,  and  called  at- 
tention to  other  sources  than  the  tonsil,  and  par- 
ticularly mentioned  the  sinuses  and  the  teeth. 

Among  the  latest  organisms  to  be  studied  in  re- 
lation to  arthritis  is  a  small  gram  negative  diplo- 
coccus,  first  observed  by  Connellan  in  1914,  while 
examining  extracted  teeth  for  Hasbrouck  and 
Palmer,  and  now  known  as  the  Connellan-King 
diplococcus.  He  was  searching  for  Endamoeba 
buccalis,  and  on  examining  abscesses  situated  upon 
the  roots  of  many  of  the  teeth  found  the  Strep- 
tococcus viridans,  and  Streptococcus  hemolyticus; 
also  a  gram  negative  diplococcus  which  he  had 
never  seen  before,  nor  could  he  find  anything  in  the 
literature  calling  attention  to  this  organism.  King 
made  cultures  from  other  parts  of  the  mouth  and 
throat,  and  the  new  organism  was  found  in  the 
crypts  of  the  tonsils  and  around  the  teeth.  It  is 
a  typical  bean-shaped,  gram  negative  diplococcus, 


8  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

slightly  smaller  than  the  gonococcus  when  it  has 
attained  its  maximum  growth  on  its  best  growing 
medium,  which  has  been  found  to  be  human  blood 
agar  with  a  little  veal  serum  added.  It  has  a  char- 
acteristic appearance  on  the  medium,  the  colony- 
being  a  light  dull  yellowish  brown  with  a  rounded 
contour,  about  the  size  of  staphylococcus  albus, 
growing  best  at  a  temperature  of  39°-40°  C. 

Dunham,  Van  Lingelshein,  Elser  and  others 
have  reported  several  gram  negative  organisms 
found  in  the  mouth  and  in  other  parts  of  the  body, 
but  this  organism  does  not  compare  with  them  and 
has  never  been  found  outside  the  mouth  and  throat, 
after  over  three  years'  searching  investigation. 
It  is  necessary,  in  preparing  the  medium,  to  use 
the  titration  method,  and  the  acidity  must  be  0.2% 
or  less. 

With  the  Hiss  sugar  serums  no  reaction  oc- 
curred except  coagulation  of  albumen,  showing  it 
is  not  a  gas  producer,  and  thus  accounting  for  the 
absence  of  pain  in  the  teeth,  where  it  was  found  in 
the  apical  abscesses. 

Cultures  have  been  made  from  the  ear,  nose  and 
accessory  sinuses,  but  all  have  been  negative  for 
this  organism.  When  found  it  has  been  in  a  ton- 
sillar crypt,  or  some  sinus  in  the  tonsillar  fossae 
after  the  tonsils  have  been  removed,  or  around  the 
roots  of  teeth;  partially  anaerobic  chambers.  It  is 
not  pyogenic,  but  is  a  powerful  toxin  producer; 
causes  local  infection,  and  is  non-infectious  for  the 
general  blood  stream. 


IN   THE   CAUSATION   OF  ARTHRITIS.  9 

Many  arthritic  or  so-called  rheumatic  joints  in 
which  this  organism  was  suspected  to  be  the  cause, 
were  aspirated:  blood  cultures  have  been  made 
from  patients  in  whom  it  was  found  and  all  have 
been  negative  for  the  organism.  A  similar  condi- 
tion is  met  with  in  the  Tetanus  and  Klebs-Loeffler 
bacilli.  It  grows  best  in  the  presence  of  moisture. 
Clinically,  the  throats  in  which  it  is  found  are  also 
moist  and  have  other  characteristic  appearances. 
The  mucosa  is  darker  than  normal,  of  a  purplish, 
unhealthy  hue,  and  the  tonsils  are  usually  rather 
small  and  submerged,  with  a  brownish  yellow 
serum  exuding  from  their  crypts.  While  the  sub- 
ject of  the  treatment  is  not  under  consideration 
here,  if  we  are  to  prove  our  case  and  make  good 
the  claim  that  arthritis  is  produced,  in  many  in- 
stances at  least,  by  a  focal  infection  from  the  teeth 
and  tonsils  and  would  be  and  are  relieved  or  cured 
by  the  elimination  of  that  focal  infection,  it  must 
be  shown  that  cases  of  arthritis  are  relieved  or 
cured  by  the  removal  of  infected  tonsils  and  teeth. 
This  has  been  done  by  many  accurate  observers. 
These  have  been  freely  quoted  throughout  this  es- 
say and  the  author  will  personally  reminisce  upon 
one.  Dozens  could  have  been  quoted  as  easily. 
Not  from  psychic  females  open  to  suggestion  and 
relieved  by  the  same,  but  by  strong  men  and  in- 
nocent children  who  knew  not  the  meaning  of  the 
word  psychology.  They  have  received  no  sugges- 
tion.    They  have  received  relief. 

It  has  happened  that  the  removal  of  infected  ton- 
sils and  teeth  has  been  followed  also  by  very  seri- 


10  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

ous  complications  due  to  the  absorption  of  chem- 
ical toxins,  but  the  contention  that  this  diplococ- 
cus  was  responsible  in  these  cases  is  strengthened 
by  the  immediate  improvement  of  the  patient  upon 
receiving  an  autogenous  vaccine  of  the  organism. 
In  1916,  in  this  country,  Morris10  reported  12 
cases  with  very  complete  history  records  showing 
the  condition  before,  during  and  after  the  opera- 
tion. In  the  tonsillar  cases  the  association  of 
pyorrhoea  is  noticeable.  The  twelfth  case  was  not 
operated  upon,  probably  not  because  the  tonsils 
were  small,  but  because  the  history  relates  ten  at- 
tacks of  gonorrhoea.  He  is  a  strong  believer  in 
the  teeth  and  tonsils  as  factors  in  causing  arthritis, 
and  has  operated  upon  many  cases  during  the  at- 
tack. He  says  that  while  no  general  conclusions 
may  be  drawn  from  so  few  cases,  it  is  encouraging 
to  note  that  the  fever  subsided  promptly  after  the 
operation  in  so  many  of  the  cases.  In  Case  2 
streptococcus  viridans  was  isolated  from  the  blood 
on  two  different  occasions,  and  within  three  days 
after  tonsillectomy  the  patient's  temperature  be- 
came normal  and  remained  so.  He  thinks  in  this 
case  the  portal  of  entry  was  through  the  tonsils, 
and  concludes  as  follows:  "In  conclusion,  it  seems 
to  the  writer  advisable,  in  patients  suffering  with 
acute  rheumatic  fever,  in  whom  evidence  of  tonsil- 
lar infection,  acute  or  chronic,  can  be  obtained,  to 
remove  the  tonsils  as  soon  as  the  joint  pains  can 
be  controlled,  provided  the  main  conditions,  as  out- 
lined in  the  body  of  the  paper,   can  be  fulfilled. 


IN  THE   CAUSATION   OF  ARTHRITIS.  11 

Further  experience  alone  can  determine  whether 
the  so-called  complications  and  recurrences  can  be 
prevented  in  this  manner." 

It  is  but  a  short  time  ago  when  almost  every 
ailment  of  the  human  body  that  could  possibly  be 
ascribed  to  an  infective  origin,  was  attributed  to 
disease  of  the  teeth  or  tonsils.  This  theory,  like 
all  other  new  proposals  or  discoveries  in  medicine, 
or,  for  that  matter,  in  any  field  of  endeavor  and 
human  activity,  was  obliged  to  pass  through  the 
usual  stages  of  reaction  characterized  by  incre- 
dulity, popularity,  acceptance  and  abuse,  and  hold 
its  place  for  a  while,  only  to  find  the  pendulum 
swing  to  the  other  extreme.  This  latter  has  hap- 
pened, and  we  are  now  fortunately  traveling  the 
middle  road,  acknowledging  many  cases  of  arthri- 
tis to  be  due  to  focal  infection  through  the  teeth 
and  tonsils,  and  also  assenting  that  many  are  of 
unknown  origin.  One  must  also  agree  with 
Irons,11  that  alveolar  abscess  and  arthritis  may  be 
coincidental,  or  that  there  may  be  other  sources  of 
infection  than  the  teeth  in  the  case  of  arthritis, 
if  we  are  only  able  to  find  them.  From  an  exam- 
ination of  an  unselected  group  of  329  patients  in 
Cook  County  hospitals,  who  were  studied  and  the 
incidence  of  all  discoverable  infectious  processes 
determined  and  tabulated,  it  was  found  that  76% 
of  the  arthritic  group  had  alveolar  abscesses. 
Other  diseases,  including  pneumonias,  respiratory, 
gastro-intestinal,  only  23%,  or  less  than  one  third 
of  the  percentage  in  the  arthritic  group.     Abnor- 


12  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

malities  in  the  tonsils  were  present  in  45%  of  the 
arthritic  group,  but  only  24%  in  the  cardio-vascular 
group,  and  in  19%  of  the  remainder.  Irons  says: 
"All  arthritis  or  other  metastatic  and  systemic 
disease  is  not  due  to  alveolar  abscess  or  to  tonsillar 
infection,  of  course,  but  the  preponderance  of  such 
lesions  in  this  group  suggests  that  these  infections 
may  play  an  important  part  in  the  production  of 
chronic  arthritis  and  similar  ailments.  ...  In 
the  Arthritic  group  therapeutic  measures  directed 
to  the  removal  of  infectious  processes  have  been 
followed  by  gratifying  results,  even  in  rather  un- 
favorable material.  Our  readmissions  for  recur- 
rences of  arthritis — which  in  former  years  were 
frequent,  some  patients  returning  as  many  as  four 
times  in  a  season — have  been  relatively  fewer,  and 
usually  of  patients  who  for  some  reason  or  other 
could  not  be  submitted  to  proper  surgical  atten- 
tion." 

King12  reports  among  his  tentative  conclusions 
drawn  from  100  cases:  "Every  case  of  septic 
arthritis,  commonly  called  rheumatism,  is  caused 
by  a  focus  of  infection  somewhere  in  the  body.  It 
may  be  found  in  the  tonsils  ...  or  in  and 
around  the  the  teeth.  .  .  .  The  most  frequent 
focus  is  found  in  the  mouth,  and  tonsils,  on  account 
of  their  crypts,  harbor  the  focus  more  frequently 
than  any  other  gland  or  organ.  .  .  .  The  in- 
fection may  become  latent  and  produce  serious 
trouble  weeks  or  months  later,  at  a  point  far  re- 
moved from  its  original  site." 


IN  THE   CAUSATION   OF  ARTHRITIS.  13 

White  and  Wright,13  reporting  56  cases  of  varied 
infections  met  with  while  working  upon  a  treat- 
ment for  Pyorrhea  Alveolaris,  say:  "The  high 
percentage  of  arthritis  cases  in  this  series  is  due 
to  the  fact  that  these  men  first  reported  for  treat- 
ment of  so-called  rheumatism,  and  the  pyorrhea 
was  detected  when  search  was  being  made  for  a 
local  focus  of  infection." 

Murray,14  reporting  on  a  study  of  848  cases  of 
tonsillectomies,  says  he  has  constantly  observed 
that  where  a  tonsil  is  a  focal  infection  and  has  been 
removed,  the  patient's  power  of  resistance  im- 
proves, and  often  remote  affections  like  arthritis 
will  disappear. 

While  Rosenow,  Klotz,  Poynton,  Payne  and 
many  others  have  worked  with  the  Streptococcus 
in  its  invasion  of  tissues  and  organs  and  have 
demonstrated  through  animal  experimentation  that 
they  can  produce  the  same  organism  in  the  same 
anatomical  position  in  the  animal  as  in  the  human 
from  whom  it  came,  they  have  worked  without 
particular  reference  to  the  dental  avenues  of  infec- 
tion, and  it  was  not  until  the  work  of  Goadby10 
that  particular  reference  to  the  tooth  avenue  of 
infection  received  systematic  or  detailed  study  in 
the  English  language.  From  1910  to  1912 
through  a  series  of  studies  he  was  able  to  produce 
experimentally  arthritis  in  rabbits.  Then,  by  the 
elimination  of  the  primary  foci  and  the  use  of  vac- 
cines to  supplement  the  elimination,  to  cure  the 
joint  conditions.     Hartzell,   in  a  paper  upon  the 


14  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

dental  path  of  infection  says,  "If  there  be  anything 
of  marked  value  in  this  paper  which  may  be  of 
future  use,  it  will  be  in  the  fact  that  it  offers  definite 
and  positive  proof  that  the  so-called  dental  path  of 
infection,  hitherto  little  appreciated,  is  shown  to 
be  important,  and  that  organisms  taken  from  the 
dental  path  have  produced  in  animals  almost  all 
of  the  same  forms  of  lesions  hitherto  described." 

That  either  the  teeth  or  the  tonsils,  or  both,  may 
be  the  source  of  infection  in  arthritis  is  well  shown 
in  a  case  operated  upon  over  a  year  ago  by  the 
writer.  The  patient  was  a  practicing  physician, 
aged  48,  who  had  been  suffering  from  vague  pains 
in  various  parts  of  his  body  for  many  months. 
Pains  in  the  back  of  his  neck  he  attributed  to  cur- 
rents of  air  from  the  top  of  his  auto  windshield; 
pain  in  the  back  of  his  legs  and  under  the  knees  to 
an  old  phlebitis  (that  had  not  bothered  him  for 
years)  following  typhoid  fever;  pains  in  his  arms 
and  shoulders  to  golf,  and  so  ad  infinitum,  until 
one  day  it  was  brought  home  to  him  in  some  man- 
ner, it  matters  not  how,  that  an  existing  pyorrhea 
alveolaris  might  be  the  source  of  his  trouble.  A 
dentist  was  forthwith  consulted  and  the  tartar 
scraped  from  off  the  roots  of  his  teeth;  the  pockets 
injected  with  emetin  and  alcresta  tablets  ingested 
almost  ad  lib.  and  the  teeth  scrubbed  with  a  solu- 
tion of  ipecac.  There  was  some  slight  improve- 
ment noted,  but  not  enough  to  satisfy  him,  and  he 
then  bethought  him  of  his  tonsils,  and  having 
set  his  mind  upon  them,  nothing  would  satisfy  him 


IN  THE  CAUSATION   OF  ARTHRITIS.  15 

until  they  were  removed,  and  as  he  had  employed 
me  many  times  to  enucleate  tonsils  from  the 
throats  of  his  patients  and  liked  the  style  of  work, 
would  have  no  one  else  remove  his  own.  As  he 
was  a  bleeder,  of  a  family  of  bleeders,  it  occurred 
to  me  to  suggest  he  take  his  tonsils  somewhere 
else.  He  persistently  refused  to  do  this,  and  when 
he  was  unsuccessful  in  his  pleadings,  he  solicited 
and  secured  the  aid  of  his  wife,  and  I  succumbed  to 
the  combined  battery.  Let  us  pass  over  the 
operation.  I  am  always  glad  to  do  so.  It  nearly 
turned  me  prematurely  gray.  The  interest  in  this 
essay  lies  in  the  result.  Sufficient  time  has  now 
elapsed  to  judge  the  result.  He  considers  himself 
a  normal,  healthy  man.  Pains  have  gone  and  he 
cannot  even  produce  them  now  as  formerly,  that 
is,  by  crossing  one  leg  over  the  other  and  resting 
one  knee  on  the  other  he  would  at  once  produce  a 
pain  in  the  hip  of  the  uppermost  leg.  In  fact,  to 
get  the  leg  upon  the  other  knee  he  was  usually 
obliged  to  assist  with  the  opposite  hand.  He  now 
crosses  his  knees  and  lets  them  stay  so  indefinitely. 
No  cultures  were  made  from  the  tonsils  (the 
haemorrhage  took  all  bacteriology  from  our 
minds),  but  they  were  odorous,  with  a  thick,  cheesy 
like  excretion  oozing  from  every  crypt  as  the  snare 
compressed  the  tissue. 

This  same  condition  has  many  times  been 
noted  by  the  writer  when  enucleating  tonsils 
for  the  relief  of  chorea,  100%  of  which  enuclea- 
tions   have   been    successful   up    to    date,    by   the 


16  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

way,  in  stopping  the  choreic  movements.  Some 
cases  will  not  be  benefited  in  the  least,  without  a 
doubt;  but  they  have  not  appeared  yet.  One 
would  be  brave  indeed  to  state  that  every  case  of 
chorea  was  or  could  be  cured  by  tonsillectomy.  No 
such  claim  is  being  made  here.  What  is  claimed 
is  this:  The  cases  of  chorea  operated  upon  by  the 
writer  were  referred  to  him  by  men  who  believed, 
in  that  special  case,  an  infection  through  a  tonsil 
to  be  the  cause  of  the  chorea.  Or  they  were  cases 
found  by  me  in  my  work  and  believed,  as  did  the 
other  men,  to  be  cases  that  would  be  benefited,  as 
far  as  their  chorea  was  concerned,  or  at  least  their 
general  health  would  be  improved,  by  removal  of 
the  tonsils  as  the  most  likely  causative  factor. 
The  results  stated  above  have  confirmed  this  opin- 
ion most  convincingly.  All  cases  of  chorea  are  not 
of  focal  infective  origin  in  all  probability.  The 
claim  that  they  are,  is  not  made.  The  claim  is 
made,  and  proven,  to  the  writer's  satisfaction,  that 
the  cases  that  appear  to  come  from  tonsil  infec- 
tions, are  diagnosed  as  such,  and  are  operated  upon 
for  relief  from  that  condition,  have  given  results 
that  would  satisfy  the  most  exacting. 

The  association  between  chorea  and  the  great 
rheumatic  group  need  not  be  gone  into  here,  as  it 
would  be  quite  outside  the  title  of  the  essay.  Suf- 
ficient it  is  to  draw  attention  to  the  fact  and  to  the 
strong  statement  of  Billings,17  who  makes  no  modi- 
fication, even,  when  he  says,  "Rheumatic  fever  and 
endocarditis  are  unquestionably  the  result  of  focal 


IN   THE   CAUSATION   OF  ARTHRITIS.  17 

infection  of  the  mouth  and  throat."     And  again, 
"Probably  the  frequent   relation  of  pyorrhoea   to 
rheumatic  fever     .     .     .     has  not  been  given  the 
etiological    importance    it    deserves."     Many    au- 
thorities do  not  agree  to  this  theory,  but  they  are 
greatly   outnumbered    when    one   compares    them 
with  the  array  quoted  by  Billings,  57  in  number, 
in  the  bibliography  at  the  end  of  the  volume,  or  by 
Dillingham,ls  with  41  references  at  the  end  of  his 
article.     It  is  indeed  strange  that  these  same  au- 
thorities are,  almost  to  a  man,  the  very  ones  who 
accept,    recognize    and    acknowledge   gonorrheal 
arthritis    to    be    of    urethral    gonorrheal    origin. 
Among  these  dissenters  may  be  mentioned  Roily,19 
who  found  blood  sterile  in  a  large  number  of  cases, 
even  when  taken  at  the  height  of  the  febrile  stage. 
He  does  not  claim  all  others  are  wrong  in  their 
contention  for  bacterial  infection  in  acute  rheu- 
matic cases  previously  reported,  but  questions  if 
mixed  infections  might  not  be  responsible  for  the 
positive  findings.     He  examined  the  blood  rather 
than  the  contents  of  the  tonsils,  because  he  claims 
the  presence  of  bacteria  on  the  tonsils,  and  not  in 
the  interior  of  the  body,  is  no  evidence  that  these 
bacteria  are  responsible  for  the  articular  rheuma- 
tism.    Yet  from  his  own  figures,  if  we  take  the 
cases  of  tonsillitis,  sore  throat,  pain  in  the  throat, 
suppurating    tonsils,    tonsils    found    red    and    en- 
larged, or  both,  tonsils  with  plugs  visible,  and  his 
so-called  coated  tonsils,  and  add  them  all  together 
we  get  an  even  500  cases  in  his  1450  patients  ex- 


18  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

amined.  Add  to  the  238  where  he  says  other  parts 
of  the  throat  were  red  and  swollen,  or  both,  and  it 
leaves  such  a  large  percentage  of  actual  throat 
cases,  even  if  he  insists  throat  cases  are  not  neces- 
sarily tonsil  cases,  that  one  hesitates  to  take  his 
objections  seriously.  And  Rolly's  argument  that 
he  did  not  find  the  organisms  in  the  blood  in  his 
cases  does  not  hold,  because  it  has  been  acknow- 
ledged by  observers  before  and  stated  by  Billings, 
that  "doubt  of  etiologic  relation  to  acute  rheuma- 
tism also  arose  from  the  fact  that  it  was  not 
usually  found  by  cultured  methods  in  the  joint 
exudate  and  circulating  blood  of  patients." 

Dick20  reports  two  cases  of  arthritis  due  to  a 
Friedlander  Bacillus  (Bacillus  Mucosus).  Re- 
peated cultures  from  the  throats  of  which  (yield- 
ing colonies  of  the  bacillus  isolated  in  pure  culture) 
produced  arthritis  experimentally  in  all  three  rab- 
bits which  were  inoculated  intravenously. 

Crowe  et  al.21  reports  on  a  series  of  1000  cases  of 
tonsillectomies,  wherein  a  histologic  examination  of 
the  tonsils  and  adenoids  removed  at  operation  was 
made  in  every  case.  Ten  per  cent  of  these  cases 
had  an  infective  type  of  arthritis.  In  the  first  31 
cases,  where  the  author  was  able  to  follow  up  the 
cases,  24  had  normal  joints.  Four  are  classified  as 
improved,  because  the  patients  are  now  able  to 
walk  without  pain,  two  are  not  improved,  and  one 
is  worse.  All  classes  improved,  except  the  old 
chronic  ankylosed  cases,  which  he  classes  as  Rheu- 
matoid Arthritis,  and  in  which  he  found  only  two 


IN  THE  CAUSATION  OF  ARTHRITIS.  19 

benefited  and  five  are  much  worse.  He  says  re- 
moval of  the  tonsils  and  adenoids  in  cases  of  rheu- 
matic fever  eliminates  one  of  the  portals  of  infec- 
tion. He  says  he  believes  this  removal  is  not  a 
very  satisfactory  therapeutic  or  prophylactic  meas- 
ure in  chorea,  and  appears  to  base  it  upon  the  fact 
that  of  23  cases  of  Sydenham's  chorea,  there  was  a 
recurrence  of  the  disease  in  eight  cases  after  the 
operation.  One  feels  like  asking,  what  about  the 
success  in  the  majority  of  the  cases?  Fifteen  is 
nearly  twice  eight.  He  advises  against  the  re- 
moval of  the  tonsils  in  the  acute  stages  of  chorea. 
The  writer  desires  to  differ  strenuously  with  this 
opinion,  and  has  had  in  his  own  practice  within  the 
last  year  over  a  dozen  cases  that  positively  refute 
the  statement  that  there  is  grave  danger.  Quite 
to  the  contrary,  he  has  had  to  date  universal  suc- 
cess in  such  cases. 

Writing  editorially  upon  this  article  the  Journal 
of  the  American  Medical  Association  says,  "Despite 
the  many  uncertainties  and  unsolved  problems 
which  still  exist,  however,  Crowe  and  his  collabor- 
ators state  that  their  records  tend  to  support  the 
evidence  of  Billings  and  others  in  regard  to  the 
importance  of  focal  infections  in  many  of  the  gen- 
eral disorders  seen  by  the  internist,  the  pediatri- 
cian, and  the  general  surgeon."  Notwithstanding 
the  statement  of  Billings  given  above,  Rosenow22 
has  studied  the  bacteria  obtained  from  joint  exu- 
date and  rheumatic  nodes  in  acute  rheumatism, 
and  found  organisms  corresponding  closely  to  the 


20  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

micrococcus  Rheumaticus  in  seven  out  of  eight 
cases.  He  claims  certain  strains  of  bacteria  as- 
sume different  cultural  and  morphological  charac- 
teristics under  certain  conditions  and  environment. 
He  classifies  the  streptococci  as  follows,  their  vio- 
lence increasing  in  the  order  named:  Hemolytic 
Streptococcus,  Streptococcus  Rheumaticus,  Strep- 
tococcus Viridans,  Pneumococcus,  and  the  Step- 
tococcus  Mucosus.  The  hemolytic  variety  has  an 
affinity  for  joint  structures,  while  the  viridans  has 
an  affinity  for  heart  valves.  No  other  reason 
seems  as  plausible  for  the  prevalence  of  rheumatic 
fever  in  children  as  the  local  infection  in  the 
throat,  mouth  and  nose. 

A  short  time  ago  a  patient  who  had  had  repeated 
attacks  of  arthritis  some  years  ago,  but  who  had 
been  free  from  an  attack  for  a  long  time,  suffered 
with  a  tonsillitis"  that  ended  in  peritonsillar  abscess 
requiring  operation  for  evacuation  of  the  pus.  Re- 
lief to  the  throat  was  immediate  upon  release  of 
the  pus,  but  the  system  had  taken  part  in  the  pyae- 
mia evidently,  for  he  had  an  attack  of  arthritis  be- 
fore his  convalescence  from  the  quinsy.  The 
writer  believes  he  would  have  been  spared  this  last 
attack,  both  of  tonsillitis  and  rheumatism,  if  he  had 
had  his  tonsils  removed  when  advised  to  do  so, 
some  time  ago. 

The  writer  is  a  firm  believer  that  neuralgias, 
neuritis  and  most  myalgias  are  all  members  of 
the  rheumatic  family.  And  with  that  as  a  basis 
for  his  reasoning,  has  repeatedly  advised  tonsillec- 


IN  THE   CAUSATION   OF  ARTHRITIS.  21 

tomy  when  no  other  source  of  infection  could  be 
ascertained.  And  the  tonsil  may  look  innocent 
enough.  A  tonsil  may  contain  foci  which  are  caus- 
ing the  most  serious  systemic  infection,  where  a 
careful  examination  may  fail  to  discover  anything 
which  would  throw  suspicion  upon  these  struc- 
tures, and  where  the  infection  in  the  tonsil  can  be 
disclosed  only  after  the  tonsils  are  removed.  The 
absence  of  an  acute  attack  of  sore  throat  at  the 
time  when  systemic  disease  developed  in  no  way 
excludes  the  tonsils  as  the  possible  focus  for  the 
trouble.  The  history  of  attacks  of  tonsillitis  in 
previous  years  should  always  throw  suspicion  on 
the  tonsils  as  the  possible  seat  of  chronic  latent 
foci,  and  when  the  systemic  condition  is  serious 
enough  to  justify  the  procedure,  the  faucial  tonsils 
should  be  enucleated  unless  foci  of  infection  can  be 
detected  elsewhere.  In  searching  for  the  cause  of 
an  obscure  systemic  disease,  and  everything  done 
to  eliminate  the  source,  one  may  be  misled  by  the 
statement  of  the  patient  that  they  have  never  had 
tonsillitis  or  a  sore  throat.  And  yet  an  examina- 
tion of  the  tonsils  will  disclose  the  presence  of  pus 
that  can  be  expressed  quite  easily.  The  tonsil 
may  or  may  not  be  enlarged.  When  it  is  distinctly 
enlarged  the  evidence  of  chronic  infection  is,  per- 
haps, more  readily  recognized  than  when  the  ton- 
sil is  shrunken.  Dillingham,  quoted  above,  says: 
"In  a  case  suffering  from  a  chronic  systemic  infec- 
tion, the  faucial  tonsil  should  always  be  under  sus- 
picion as  the  most  frequent  source  of  the  trouble, 


22  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

and  in  cases  where  no  other  foci  can  be  detected, 
one  should  not  hesitate  to  consider  the  removal  of 
the  tonsil,  provided  the  systemic  infection  is  severe 
enough  to  warrant  the  operation,  even  in  the  case 
where  the  history  of  the  patient  and  the  examina- 
tion of  the  tonsil  discloses  no  positive  evidence  of 
the  tonsillar  origin  of  the  trouble."  The  writer 
wishes  to  heartily  endorse  these  sentiments.  As 
shown  by  the  case  of  the  physician  and  many 
others,  especially  the  type  mentioned  when  the 
claim  was  made  that  neuralgia  was  of  the  rheu- 
matic family.  Cases  have  been  operated  upon  by 
me  after  internists  have  eliminated  all  other  pos- 
sible causes  for  the  systemic  disturbance;  and  while 
the  tonsils  in  some  cases  have  not  been  inflamed 
(some  never  having  had  an  attack  of  tonsilitis), 
and  in  some  cases  were  not  even  able  to  be  seen 
between  the  pillars,  even  with  counter  pressure 
externally  on  the  neck,  were  found,  when  removed, 
to  have  been  foul-smelling  beds  of  pus  of  a  cheesy 
consistency;  and,  best  of  all,  their  removal  has 
given  relief  and  cure  to  the  various  pains  through- 
out the  system.  If  one  is  uncertain,  it  is  no  crime 
to  remove  the  tonsils  as  one  more  possible 
source  of  infection  removed.  Another  reason  is, 
because  with  properly  carried  out  technique  there 
is  less  danger  and  inconvenience  to  the  patient  than 
accompanies  almost  any  other  procedure  (surely 
less  for  the  great  gain  that  may  be  accomplished), 
and  without  losing  or  interfering  with  some  func- 
tioning structure.     The  tonsils  are  only  one  of  the 


IN  THE   CAUSATION  OF  ARTHRITIS.  23 

many  portals  through  which  infection  may  enter. 
But  it  is  one  of  the  easiest  to  close.  So  even  an 
experimental  operation  may  be  justifiable  in  serious 
cases. 

I  have  in  mind  a  case  where,  after  a  thorough 
eliminative  diagnosis  had  been  made,  the  patient 
had  been  referred  to  me  to  find  if  the  tonsils  were 
the  possible  source  of  a  most  persistent  refractory 
neuritis  in  the  shoulder  and  arm.  No  inflamma- 
tion of  the  tonsils  could  be  made  out,  nor  could  one 
justly  accuse  those  two  very  small,  innocent-look- 
ing glands,  that  had  never  given  their  possessor 
even  so  much  as  a  suggestion  that  she  owned  them, 
of  being  the  cause  of  her  trouble,  even  through  the 
greatest  stretch  of  the  surgeon's  imagination.  The 
patient  persisted  that  the  physician  had  eliminated 
all  causes  but  that  one,  and  she  proposed  to  have 
that  one  eliminated.  Operation  was  performed. 
Tonsils  were  not  larger  than  the  end  of  your  finger 
when  removed,  but  during  the  removal  the  operat- 
ing room  was  filled  with  the  odor  one  gets  when 
the  abdomen  is  opened  upon  a  ruptured  appendix. 
Two  weeks  from  the  operation  there  was  no 
shoulder  or  arm  pain,  and  there  has  been  none 
since.  Many  more  cases  of  similar  character  could 
be  cited.  So  the  writer  feels  he  should  be  par- 
doned if  he  appears  to  take  too  firm  a  stand  upon 
the  platform  that  says,  "The  Teeth  and  Tonsils 
do  play  an  important  role  in  Arthritis."  And,  if 
not  pardoned,  is  willing  to  take  punishment  for  say- 
ing he  thinks  they  play  the  leading  role.  A  long 
and  careful  tabulation  by  the  writer  has  been  made 


24  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

of  the  cases  treated  by  or  through  him  by  dental 
and  tonsillar  treatment,  showing  the  condition  of 
the  patients,  both  general  and  local,  before  and 
after  this  treatment.  It  is  lengthy,  and  would 
cover  many  pages  with  tables,  the  persual  of  which 
would  tend  to  no  good  offices  more  than  can  be 
obtained  through  the  statement  of  the  observer  as 
to  what  his  findings  are  from  the  series  and  what 
conclusions  he  draws  therefrom.  Those  conclu- 
sions are  in  accord  with  the  findings  of  Billings, 
Rosenow,  Vanderhoof,24  who  although  only  de- 
scribing six  cases  in  his  paper,  reports  on  23  in 
which  the  tonsils  were  examined  at  the  laboratory 
post  operative;  with  Schraeder20  in  his  clear-cut, 
well-substantiated  claim  of  tooth  origin  for  many 
infections;  with  Gibbes26  in  his  demonstration  that 
the  X-Ray  is  an  aid  in  determining  the  dental  path 
of  infection;  with  Lesemann,27  who  says  in  his  con- 
clusion, "Removing  the  tonsils  and  making  vac- 
cines from  the  contained  bacteria  in  such  diseases 
as  rheumatism,  endocarditis,  arthritis,  some  cases 
of  neuralgia  and  nephritis,  is  a  duty  when  other 
treatment  fails";  with  Osmond28  and  his  conclu- 
sions following  observations  made  upon  cases 
diagnosed  through  X-Ray  aid;  with  Gearhart,29 
Crane  Reede  and  Barnes  in  their  "known  facts  re- 
garding the  habits  of  certain  types  of  micro- 
organisms that  give  important  evidence  respecting 
their  tissue  affinities";  with  Shuman30  in  his  very 
practical  talk  to  his  general  practitioner  confreres 
when  he  requests  them  to  be  on  guard  to  observe 


IN  THE   CAUSATION   OF  ARTHRITIS.  25 

the  focal  infections  through  the  teeth  and  tonsils 
in  their  systemic  diseases;  with  Higginbotham,31 
whose  vigorous,  fearless  article  is  well  worth  the 
time  to  read  it;  and  with  all  progressive  men  who 
fear  not  to  travel  toward  the  light.  An  evidence 
of  Higginbotham's  courage  may  be  had  from  the 
following  excerpt  from  his  article  referred  to 
above: 

"Tradition  still  controls  our  dealing  with  the 
acutely  inflamed  tonsil:  we  cling  to  ancestral  cus- 
toms, forgetting  that  a  surgical  principle  must  ap- 
ply to  all  parts  of  the  body.  Can  it  be  said  that 
the  antiquated  treatment  of  the  inflamed  appendix 
or  carbuncle  is  less  efficient  than  the  treatment  we 
still  give  the  inflamed  tonsil  ?  If  the  medical  treat- 
ment of  tonsillitis  is  right,  the  surgical  treatment 
of  appendicitis  is  wrong:  a  scientific  principle  can- 
not be  shifted  to  suit  conditions. 

"A  few  decades  back  no  one  understood  the  com- 
plications of  appendicitis;  to-day  this  is  common 
knowledge.  To-day,  too,  the  sequelae  of  tonsillitis 
are  well  known,  but  no  consistent  effort  is  made  to 
prevent  them.  The  conscientious  abdominal  sur- 
geon removed  the  appendix  early  in  the  first  attack 
in  the  same  way  the  conscientious  throat  surgeon 
will  come  to  remove  the  tonsils.  Waiting  to 
operate  the  appendix  in  the  interim  exposes  the 
patient  to  subphrenic  abscess  and  general  periton- 
itis; waiting  to  operate  the  tonsil  in  the  interim  ex- 
poses the  patient  to  arthritis,  nephritis  and  endo- 
carditis. The  treatment  for  the  appendix  is  the 
treatment  for  the  tonsil." 


26  THE  ROLE  OF  THE  TEETH  AND  TONSILS 

And  the  following  which  is  too  good  to  quote. 
Complete  enjoyment  can  be  had  only  by  getting 
it  direct  as  published  in  the  Journal  of  the  American 
Medical  Association  for  March  24,  191 7. 


"Current  Reviews  Regarding  the  Tonsils  and 
Their  Surgical   Removal. 

"To  the  Editor:  Your  editorial  on  this  subject 
(the  Journal,  March  17,  1917,  page  851)  is  at  least 
amusing,  if  not  scientific.  Experience  is  of  more 
value  than  theory;  therefore,  if  you  wish  to  discuss 
a  subject  scientifically,  you  should  place  yourself 
in  a  position  to  see  clinical  results.  Consequently 
come  to  western  Kansas  where  'inflamed  tonsils' 
are  removed  daily  for  the  cure  of  arthritis,  ne- 
phritis, endocarditis  and  the  prevention  and  cure  of 
otitis  media  and  its  complications,  as  well  as  the 
'tonsillitis.'  Come  out  where  we  treat  'diphtheritic 
tonsillitis'  by  removing  the  foci  of  infection  without 
administering  'antitoxins.' 

"Thomas  Higginbotham,  M.  D., 
"Hutchinson,  Kansas." 


There  seems  to  be  a  preponderance  of  evidence 
on  the  side  of  those  who  claim  the  teeth  and  ton- 
sils play  an  important  role  in  the  production  of 
Arthritis. 


IN  THE   CAUSATION   OF  ARTHRITIS.  27 

The  most  ardent  advocates  do  not  claim  all 
cases  of  rheumatism  have  their  origin  through 
these  ports  of  entry,  but  claim  to  have  shown  a 
great  number  of  them  do  come  from  that  source. 

The  writer  is  of  that  goodly  company  and  so 
leaves  his  case  before  you. 


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